Blogs from the FNP Community

ADAPT: Healthy relationships clinical adaptation (2)

11 December 2017

We’re working with 11 FNP sites from around the country and Dartington Service Design Lab to co-design a number of adaptations to the FNP programme which we will put through rapid-cycle testing over the next year. The ADAPT project (Accelerated Design and Rapid Programme Testing), is part of the wider FNP Next Steps programme.

In the sixth of our clinical adaptations blog series, Dorothy Porter, Supervisor of the Lambeth team, outlines the adaptation they’re developing. Their focus is on promoting healthy relationships with clients.

Lambeth has nationally high rates of domestic abuse and in the 2016 enrolment cohort for Lambeth 30% of clients admitted to having been abused by someone close to them, and 22% reported physical and sexual abuse in the past year. Yet, in reality, we felt that these numbers were likely to be higher as we know that some clients don't mention these problems to their nurses. We knew that some mums we work with were experiencing conflict or controlling/coercive behaviour in their relationships, and as a team, we felt strongly about creating an adaptation that could help change this.

Clinical adaptation development and aims

The main aim of our clinical adaption is to reduce conflict and violence in our client’s intimate partner relationships, ultimately reducing a baby’s exposure to conflict and violence. We want to increase our clients understanding of what constitutes both a healthy and unhealthy relationship, and the harmful effect intimate partner violence (IPV) can have on their own wellbeing, and the wellbeing and lasting impact on their child.

To better prepare nurses for delivering the adaptation, each nurse in the team received training around relationships, IPV and its impact; conflict resolution and couples in abusive relationships; mindfulness and emotional intelligence; and local specialist IPV services and referral pathways.

We open the topic area early in pregnancy visits, beginning with the universal materials, promoting the ideal environment for a baby to thrive, introducing information on emotions, and what can constitute a healthy/unhealthy relationship.

We then use an assessment tool with clients (amended CADRI risk assessment), combined with a nurse’s professional judgment, to determine whether or not a client is the victim of IPV and start the process that allows clients to reflect on acceptable behaviours in relationships. Depending on the level of need, nurses will continue to deliver a universal offer or a more targeted intervention with their client.

The universal offer is delivered to all clients, in addition to usual programme materials, and covers:

Information on healthy and unhealthy relationships

What is IPV and its effects on victims’ physical and mental health?

Seeing the world from the baby’s perspective, and consideration of the impact of IPV (mentalisation)

Developing emotional intelligence

Developing communication skills and conflict resolution skills

Building self-efficacy.

If a client is currently in a high conflict relationship, or has been in an abusive relationship in the past, then a targeted intervention is delivered depending on client’s individual needs and to ensure we are effectively safeguarding the mother and child.

For clients in high conflict, we use materials focused on conflict management skills and introduce them to online resources for relationship support

For clients in abusive relationships, we complete further assessment to identify risk using the local assessment tools and refer to social care/MARAC and specialist IPV services where necessary. We support a smooth referral to ensure the victims or perpetrators get the help they need to ensure safeguarding the child continues to be our paramount consideration. If appropriate, we can also refer clients to the Freedom Programme.

For both of these groups, we will continue to use materials to support building self-efficacy, in addition to materials as part of the universal offer.

Working with clients

During the development of the adaptation we held focus groups with our clients to ask them about the topic area and how they would feel discussing IPV in sessions with their family nurses.

In response to this we made changes to the materials based on client’s recommendations, which not only strengthened the relevance of our tools but allowed clients to feel a part of the process. We were heartened by the client’s knowledge of the subject, and honesty and openness in discussing their relationships.

What we hope to achieve

We want to ensure all young parents and their children grow up in an environment where they can thrive, free from the negative impact of IPV. By increasing family nurse confidence and skills to promote healthy relationships, we can ensure that all young parents have an opportunity to make positive changes for themselves and their families. We hope to provide an early opportunity for young parents to begin to think about their own emotional lives, and how that impacts on their relationships.

Anecdotally, nurses in Lambeth are hearing from clients that it has been powerful to discuss their relationships and to understand that behaviours many had considered ‘normal’ were often controlling and coercive, not realising that IPV isn’t always physical. By using tools to reduce anxiety around discussing domestic violence may impact on clients future decisions in identifying positive and supportive relationships.